Provider Demographics
NPI:1689715641
Name:VESELY, MARK R (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:VESELY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-328-5793
Mailing Address - Fax:410-328-0248
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-5793
Practice Address - Fax:410-328-0248
Is Sole Proprietor?:No
Enumeration Date:2007-02-10
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD67290207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS062-0331OtherCAREFIRST BC/BS REGIONAL
MD414670100Medicaid
MD932536-01OtherCAREFIRST BC/BS
MDP00650026Medicare PIN
MD932536-01OtherCAREFIRST BC/BS